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APPENDIX VIII
II. SUB-SAMPLE SURVEY PROFORMA
(for those registered in the study)
Name : Age : Sex : SSS No. :
Village : ICMR Regd. No.
I. Geriatric Clinic
1. What are the intervention measures carried out to you in the geriatric clinic?
Medical intervention 1
Family/Social intervention 2
Economic intervention 3
None 0
   
2. Do you think that adequate treatment facilities exist un the geriatric clinic?
Yes 1
No 0
If no, what else do you expect?  
More doctors 1
More availability of costly drugs 2
Injections 3
Others (specify)  
   
3. How frequently do you attend the geriatric clinic?
Once a week 1
Once a fortnight 2
Once a month 3
Whenever ill 4
   
4. Are you satisfied with the services rendered through the geriatric clinic?
Yes 1
No 0
If yes, reasons  
More attention and care 1
Separate examination 2
Patient hearing to health problems 3
Specific health education 4
Others (specify)  
If no, reasons  
Inadequate attention and care 1
Personnel not helpful 2
Inadequate drugs 3
Health problem not solved 4
Not easily accessible 5
Others (specify)  
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